Early use of targeted blood patch in spontaneous intracranial hypotension presenting with bilateral subdural hematomas and acute infarcts.

Background: Spontaneous intracranial hypotension (SIH) is a rare but important condition characterized by cerebrospinal fluid (CSF) leakage, typically presenting with postural headaches. In severe cases, SIH can result in subdural hematomas (SDHs), brain herniation, and acute infarcts. The 2023 SIH guidelines recommend starting with nontargeted epidural blood patches as the initial treatment, with up to two attempts before considering a targeted patch. Nontargeted patches are effective in most cases by distributing blood widely in the epidural space. However, in rapidly deteriorating patients, targeted blood patches may be necessary, especially when a specific leak site has been identified. This report highlights the importance of timely, targeted interventions in severe SIH cases. Case Description: A 34-year-old male presented with a 6-month history of worsening headaches, impaired mobility, and stupor. On admission, his Glasgow Coma Scale was 12, which rapidly deteriorated to 5. Imaging revealed bilateral chronic SDHs, cerebellar tonsillar herniation, and signs of intracranial hypotension despite no history of trauma or anticoagulant use. Initial surgical evacuation of the hematomas failed to improve the patient's neurological status. Subsequent magnetic resonance imaging and computed tomography myelogram identified a CSF leak at the T12 level. Given the patient's critical state and rapid neurological decline, we opted for a targeted epidural blood patch at the L1/2 level. This intervention led to significant clinical improvement, with follow-up imaging demonstrating a reduction in the subdural collections and resolution of the leak. The patient fully recovered and remained asymptomatic at a 6-month follow-up. Conclusion: This case highlights the need for flexibility in SIH management, particularly in severe cases with acute neurological decline. While nontargeted blood patches are typically recommended, early use of a targeted patch when imaging identifies the leak can lead to faster resolution and improved outcomes. Personalized treatment strategies are essential for managing complex SIH presentations and preventing further neurological complications.